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Knowledge of pregnant women on mother-

to-child transmission of HIV, its prevention,
and associated factors in Assosa town,
Northwest Ethiopia
This article was published in the following Dove Press journal:
HIV/AIDS - Research and Palliative Care
5 May 2016
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Solomon Abtew [email protected]

Worku Awoke
Anemaw Asrat
College of Medicine and Health
Sciences, Bahir Dar University,
Bahir Dar, Ethiopia

Correspondence: Solomon
Abtew College of Medicine and
Health Sciences, Bahir Dar
University, PO Box 693,
Bahir Dar, Ethiopia
Email
Introduction: HIV/AIDS is a town. Based on the flow of antenatal care attendants, the calculated sample size was
leading cause of death of children in proportionally allocated to the health facilities before data collection. Following this,
sub-Saharan African countries. systematic sampling method was used, and data were collected using an interviewer-administered
Almost all HIV-positive children questionnaire. Bivariate and multivariate binary logistic regression analysis was done using
acquire infection through mother-to- SPSS version 20 statistical packages.
child transmis- sion (MTCT) of HIV. Result: A total of 386 pregnant women participated with a response rate of 97%, and 222
Successful intervention toward (57.5%) of them had full knowledge about the three critical modes of HIV transmission from
prevention of mother-to-child mother to child, but only 67 (17.4%) knew the possible prevention methods. Knowledge on
transmission (PMTCT) and MTCT of HIV was positively associated with women who had sufficient knowledge on
achieving the goal of eliminating the HIV/AIDS (adjusted odd ratio [AOR] 2.86, 95% confidence interval [CI] 1.54–5.32),
new HIV infection is highly women who had a favorable attitude to provider-initiated HIV counseling and testing (AOR
dependent on everyone; especially, 2.19, 95% CI 1.22–3.92), and women who did not expect any partner’s reaction to
women of child-bearing age should positive HIV test result after testing (AOR 1.58, 95% CI 1.01–2.49). Correspondingly,
have accurate and up-to-date knowledge on PMTCT of HIV was posi- tively associated with women who had sufficient
knowledge about HIV transmission, knowledge on HIV/AIDS (AOR 2.64, 95% CI 1.24–5.65), women who had favorable
risk of transmission to babies, and attitude toward provider’s counseling and testing (AOR 4.27, 95% CI 1.95–9.34), and
possible interventions. However, women who did not expect any partner’s reaction to positive HIV test result after testing
knowledge of MTCT of HIV, its (AOR 3.56, 95% CI 1.58–8.01).
prevention, and associated factors Conclusion: Knowledge on MTCT and its prevention among women is low in the study area.
among women was not well studied We recommend more efforts to be exerted on improving women’s knowledge of PMTCT of
in Benshangul Gumuz Region HIV. Keywords: pregnant women, mother-to-child transmission and prevention, Assosa
(Ethiopia).
Methods: A facility-based cross- Introduction
sectional study was conducted The HIV pandemic still remains an issue of major concern on a global scale. A total
involving 398 pregnant women who of
attended antenatal care services at 35.3 million people are living with HIV; of these, an estimated 2.3 million are
governmental health institutions from
newly infected.1 Sub-Saharan Africa contributes more than two-thirds (69%) of the
February to March 2014 in Assosa
global

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Abtew et Dovepres
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infected population. Children under the age of 15 account women’s knowledge on
for 3.4 million of the global number of infected, while sub-
Saharan Africa alone contributes to 90% of this burden.2
The most significant source of HIV infection in
children and infants is transmission of HIV from mother to
child during pregnancy, childbirth, or breastfeeding. Without
inter- vention, the risk of transmission varies ranging from
5% to 10% during pregnancy, 10% to 15% during
labor/delivery,
and 5% to 20% through breastfeeding.3,4
Ethiopia is also one of the largest epidemic countries in
sub-Saharan Africa. The national HIV prevalence estimate
was 1.5%, but the prevalence in women was 1.9% in
2011.5 Increased incidence of HIV in pregnant women
would ulti- mately lead to increased incidence of HIV in
children. Among the total 137,494 new HIV infections,
10% were children infected mainly due to vertical mother-
to-child transmission of HIV (MTCT).6,7
The proportion of HIV-positive mothers identified at sites
of prevention of mother-to-child transmission (PMTCT) of
HIV was only 22.1% in 2010, and at the national PMTCT
services scale-up site was 61.9%.8 From this PMTCT
service site, only 75.5% of antenatal care (ANC)
attendants were tested for HIV.6 According to the
Ethiopian Demographic and Health Survey of 2011, only
34% and 9.9% of moth- ers received antenatal care from
health professionals, and delivered at health institutions,
respectively.5 To cope with the challenges, the Federal
Ministry of Health planned to rapidly increase
antiretroviral (ARV) service utilization to 77% of eligible
pregnant women by 2015 as an intervention to PMTCT.7,8
But only 9.3% of pregnant women received ARVs in
2011. This also limits access to mothers and their babies
who might require PMTCT intervention.6,7
Nowadays, for the phase of elimination of MTCT of
HIV, a combination of ARVs, elective cesarean section,
and abstinence from breastfeeding is recommended,
through which it is possible to reduce MTCT of HIV to
,2% in developed countries. This is still not possible in
resource- limited countries. Primary prevention is
considered the most important way to decrease MTCT of
HIV.9 So, strengthening the integration of PMTCT services
with maternal, sexual, reproductive health, and family
planning services in health facilities is the most critical
priority outlined for achiev- ing the PMTCT targets. 7 One
of the pillars of PMTCT and the most cost-effective way is
increasing the knowledge of pregnant mothers.
Several authors have argued that regardless of
widespread information, education, and communication
campaigns, and the extension of PMTCT services,
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 Dovepres Knowledge of mother-to-child HIV transmission and its
risk s factors of MTCT of HIV and periods of prevention proportion formula con- sidering the
single-population
transmission is greatly limited. This has significantly following assumptions; 95% confidence interval (CI), 56%
contributed to the ineffectiveness of the PMTCT pregnant women had comprehensive knowledge on
strategy.10,11 PMTCT over the years has been an area HIV/AIDS taken from another study,15 margin of error
of interest to many with a good number of studies
carried out to access knowledge level of people. But
women’s knowledge of MTCT of HIV in Ethiopia is
particularly low when compared to other East
African countries. More than 65% of women in
Kenya, Rwanda, Tanzania, and Uganda know about
MTCT of HIV compared to 42% in Ethiopia.12
Knowledge on MTCT and PMTCT of HIV and
factors that facilitate or hinder it is an important
aspect of study among pregnant women, to facilitate
PMTCT. In addition, it has not been studied in the
context of Assosa town health facilities. The findings
of the study will assist health professionals,
programmers, and partners in refocusing their
approach in the management of women during ANC
follow-up for tak- ing appropriate interventions so as
to increase knowledge of pregnant women to
promote primary prevention and early treatment to
tackle HIV from MTCT.

Methods
A facility-based cross-sectional study was conducted
from February to March 2014 in Assosa town.
Assosa town is the capital city of Benshangul
Gumuz, Regional State, located Northwest of
Ethiopia at 680 kms from Addis Ababa. Accord- ing
to the 2007 Central Statistics Agency report, the total
population of the town was 24,214 (11,751 were
females, and 12,463 were males). Amhara, Berta,
and Oromo are predominant ethnic groups living in
the town. Orthodox Tewahido, Muslim, and
Protestant are the common religions. Amharic is the
official language; moreover, other languages like
Rurtangna and Oromifa are spoken widely.13
Adminis- tratively, the town is structured into four
urban Kebeles. It has one health center, one general
hospital, and seven pri- vate clinics. None of the
clinics perform PMTCT services, but both
governmental health facilities (hospital and health
center) currently provide ANC and PMTCT services
for pregnant mothers.14
The source population was all pregnant women
who attended ANC services in Assosa town public
health facilities. Pregnant women of child-bearing age,
who were selected by sampling procedures during the
study period in Assosa town public health facilities,
were studied. The sample size was calculated using
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Abtew et Dovepres
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0.05, and with the addition of 5% nonresponse rate. With consents were obtained from Benshangul Gumuz Regional
this assumption, the total calculated sample size became Health Bureau, Assosa Town Health Administration, and
398. First, the sample size was proportionally allocated to health facilities before data collection. Written consent
the two health facilities based on the flow of ANC clients. was also obtained from each participant, and
Second, after the completion of the service, individual confidentiality was assured before conducting the data
study participants were selected by systematic random collection. Participants were given the right to withdraw
sampling method by reviewing the chart. Finally, during from the study at any time without any requirements.
selection, the first pregnant woman was selected randomly
by lottery technique, and then every other ANC follower Data management and analysis
was included in the study. All collected raw data were entered into a computer by Epi
Info 3.5.3 version software. Then, the data were exported
Operational definitions to SPSS version 20 statistical package software for
MTCT knowledge analysis. Descriptive statistics such as proportion and
Knowledge index was built from the answers to three frequencies were used to describe the study population in
questions (MTCT during pregnancy, during delivery, and relation to relevant variables. Bivariate analysis was done
through breastfeeding); then, the index was categorized as for all explanatory variables in relation to knowledge on
full knowledge if the participants answered all these three MTCT and PMTCT of HIV, and those variables with
questions, and not full knowledge if they answered less P,0.2 were entered into multivariate logistic regression
than three questions.
analysis using the backward stepwise method. The model
was checked by using Hosmer and Lemeshow test of
PMTCT knowledge fitness.
Knowledge index was built from the answers to three
ques- tions (using antiretroviral therapy [ART] drugs, safe
Results
delivery, and only breastfeeding up to 6 months); then, the
From the total 398 pregnant women expected to be
index was categorized as not full knowledge (score ,3)
included in this study, 386 participated fully yielding a
and full knowledge (score 3).
response rate of 97%. Of these participants, around three-
quarters were urban residents. More than half of the study
Knowledge of HIV/AIDS
participants (57.3%) were within the age range of 20–29
Knowledge index was built from the answers to 13 ques-
years. Three hundred and thirty-two (86%) were Muslim
tions: four questions on knowledge of HIV prevention,
and Orthodox Christians. Regarding ethnicity, number of
four questions on knowledge of HIV transmission, and
participants from Amhara, Oromo, and Berta ethnic groups
five on misconceptions about modes of HIV transmission.
was 175 (45.3%), 65 (16.8%), and 89 (23.1%),
Based on the responses to these knowledge questions, the
respectively. More than three- quarters of the respondents
index was categorized as insufficient knowledge (score
attended formal education from elementary to higher
#6) and sufficient knowledge (score 7–13).
level, whereas the rest were not attending any formal
education. One hundred and forty-five (37.6%) ANC
Data collection and quality control followers were housewives, 123 (31.9%) were employed
The questionnaire was prepared in simple words by
by either government or private institutions, and 58 (15%)
review- ing pertinent literature.15–17 It was pretested in the
were farmers. Almost half of pregnant mothers (50.8%)
same setup prior to the actual data collection. Training was
had an income of $1,000 Ethiopian Birr for their
given to data collectors and supervisors. During data
household expenditure per month (Table 1).
collection, complete- ness of the questionnaire was
checked by supervisors daily. Data coding, cleaning, and
Knowledge of MTCT and its
verification were performed to assure the quality of data.
prevention
Ethical consideration More than half of the respondents (57.5%) had full
Ethical clearance and approval was obtained from Bahir knowledge about MTCT of HIV, but only 67 (17.4%) had
Dar University, College of Medicine and Health Sciences. knowledge on PMTCT of HIV/AIDS. Regarding
Written transmission mode, 33.5%, 33.6%, and 32.8% of mothers
said that transmission of HIV from mother to child
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 Dovepres Knowledge of mother-to-child HIV transmission and its
s
occurred during pregnancy, during delivery, and through prevention
breastfeeding, respectively. On the other hand, 36.9%,
34.9%, and 28.2% of respondents

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Table 2 Knowledge on MTCT and PMTCT among
pregnant women attending antenatal care services in
governmental health facilities of Assosa town,
Table 1 Sociodemographic characteristics of pregnant Northwest Ethiopia, 2014 (N386)
women attending antenatal care services in governmental Variables Number Perce
health facilities of Assosa town, Northwest Ethiopia, nt
2014 (N386) Full knowledge on MTCT
Variables Number Perce Yes 222 57.5
nt No 164 42.5
Age (years) MTCT could occur*
#19 104 26.9 During pregnancy 290 33.5
20–29 221 57.3 During delivery 291 33.6
30–45 61 15.8 During breastfeeding 284 32.8
Residence Full knowledge on the existence of intervention to minimize
Rural 88 22.8 MTCT
Urban 298 77.2 Yes 67 17.4
Ethnicity No 319 82.6
Amhara 175 45.3 PMTCT could be by*
Berta 89 23.1 ART drugs 187 36.9
Oromo 65 16.8 Only breastfeeding up to 6 177 34.9
months
Shinasha 24 6.2
Safe delivery 143 28.2
Others 33 8.6
Note: *Analysis was done using multiple responses.
Religion
Abbreviations: ART, anti-retroviral treatment; MTCT, mother-to-child
Orthodox Christian 165 42.7 transmission; PMTCT, prevention of mother-to-child transmission.
Muslim 167 43.3
Protestant 49 12.7 2.2 times (AOR 2.19, 95% CI 1.22–3.92) more likely to
Catholic 5 1.3
have better knowledge on MTCT of HIV than those who had
Educational status
Cannot read and write 47 12.2
Read and write 40 10.4
Grade 1–8 88 22.8
Grade 9–12 94 24.4
Grade .12 117 30.3
Occupation
Merchant 32 8.3
Farmer 58 15.0
Employed 123 31.9
Student 28 7.3
Housewife 145 37.6
Marital status
Unmarried 12 3.1
Married/living together 364 96.1
Divorced 3 0.8
Household expenditure (Ethiopian Birr/month)
No response 96 24.9
$1,000 196 50.8

knew that effective utilization of ART drugs, only breast-

feeding up to 6 months, and having safe delivery can prevent
MTCT of HIV (Table 2).

Factors affecting knowledge on MTCT

Compared to women who did not have sufficient
knowledge on HIV/AIDS, those who had sufficient
knowledge on HIV/ AIDS were 2.9 times (adjusted odd
ratio [AOR] 2.86, 95% CI 1.54–5.32) more likely to
have better knowledge on MTCT of HIV. Women who
had a favorable attitude to provider-initiated HIV testing
and counseling (PITC) were

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 Dovepres Knowledge of mother-to-child HIV transmission and its
a lesss favorable attitude. Pregnant women who did not prevention

expect any partner’s reaction to positive HIV test

result after testing were 1.6 times more likely (AOR
1.58, 95% CI 1.01–2.49) to have knowledge on
MTCT of HIV than those who expected negative
reaction from their partner. Age, ethnicity, religion,
residence, educational status, monthly household
expen- diture, occupation, and marital status of
respondents were significantly associated with
knowledge on MTCT of HIV among ANC followers
in the bivariate analysis, but all these variables did
not retain their significance for multivariate analysis
(Table 3).

Factors affecting knowledge on

PMTCT
There was a statistically significant difference of
knowl- edge on PMTCT of HIV among women with
respect to their monthly household expenditure;
participants who had .1,000 Ethiopian Birr for
monthly expenditure were
3.5 times (AOR 3.46, 95% CI 1.26–9.51) more likely
to
have better knowledge of PMTCT of HIV as
compared to those who had #1,000 Ethiopian Birr.
Respondents who had full knowledge on MTCT of
HIV were 3.3 times (AOR 3.32, 95% CI 1.60–
6.92) more likely to have knowledge on PMTCT of
HIV than those who did not have. Those respon-
dents who had a favorable attitude to PITC were 4.3
times (AOR 4.27, 95% CI 1.95–9.34) better
knowledgeable than those who had a less favorable
attitude to PITC, and respon- dents who did not
expect any partner’s reaction to positive HIV test
result after testing were 3.6 times (AOR 3.56, 95%
CI 1.58–8.01) more likely to have knowledge on
MTCT of HIV than those who expected a negative
reaction from their

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Abtew et Dovepres
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Table 3 Association between knowledge of MTCT and explanatory variables among pregnant women attending
antenatal care services in governmental health facilities of Assosa town, Northwest Ethiopia, 2014 (N386)
Variabl Full knowledge on COR (95% CI) AOR (95% CI) P-
es MTCT value
Yes No
Residenc
e
Urban 185 113 2.57 (1.39–3.66) 1.61 (0.95–2.73) 0.077
Rural 37 51 1.00 1.00
Expected partner’s reaction to positive HIV test result
Positive 158 90 2.03 (1.33–3.10) 1.58 (1.01–2.49) 0.047
Negative 64 74 1.00 1.00
Sufficient knowledge on HIV/AIDS
Yes 203 122 3.68 (2.05–6.61) 2.86 (1.54–5.32) 0.001
No 19 42 1.00 1.00
Notes: The assumptions for the application of multivariate logistic regression analysis were fulfilled by using Hosmer and Lemeshow test, and the model was
adequately fitted (P0.151). For explanatory variables having more than two categories, the overall significance of P-value was used. Significant values
are in bold.
Abbreviations: MTCT, mother-to-child transmission; COR, crude odds ratio; CI, confidence interval; AOR, adjusted odds ratio.

partner. Age, ethnicity, occupation, number of ANC visits, of HIV. This proportion was much lower than from
knowledge on HIV/AIDS, and stigmatized attitude toward Ghana, Nigeria, and Gondar (87.7%, 74.5%, and 88.5%,
people living with HIV/AIDS were significantly respec- tively).18–20 However, this proportion was a little bit
associated with knowledge on PMTCT of HIV among ANC higher than from Tanzania (50%) and South Africa
followers in the bivariate analysis, but all of these variables (38.3%).21–22 The poor result in this study may be due to
did not retain their significance in multivariate analysis lack of proper counseling by health professionals during
(Table 4). their ANC visit, or poor health education in the health
facilities, especially regarding the three critical modes of
Discussion HIV transmission from mother to child.
Improving knowledge on MTCT and PMTCT of HIV Lack of knowledge on MTCT of HIV among ANC fol-
among populations at higher risk of HIV infection is lowers contributed to the transmission of HIV from mother
essential in implementing comprehensive HIV responses to children. In this study, a small proportion (17.5%) of
like ARV pro- phylaxis for children who will be born from mothers knew that PMTCT of HIV could be prevented by
HIV-exposed mothers, initiating ART drugs for mothers use of ARV drugs, by only breastfeeding up to 6 months,
based on option B rules, and preventing extended and safe delivery. This proportion was less than that from
pregnancies. In this study, 57.5% of ANC followers had
Addis
full knowledge about MTCT

Table 4 Association between knowledge of PMTCT and explanatory variables among pregnant women
attending antenatal care services in governmental health facilities of Assosa town, Northwest Ethiopia, 2014
(N386)
Variables Full knowledge on COR (95% CI) AOR (95% CI) P-
PMTCT value
Yes No
Household monthly expenditure (Ethiopian Birr/month)
No response 21 75 4.98 (1.79–13.86) 7.58 (2.49–23.09) 0.002
$1,000 41 155 4.71 (1.80–12.35) 3.46 (1.26–9.51)
,1,000 5 89 1.00 1.00
Sufficient knowledge on HIV/AIDS
Yes 65 260 7.38 (1.76–30.97) 3.65 (0.78–16.99) 0.099
No 2 59 1.00 1.00
Full knowledge on MTCT
Yes 56 166 4.69 (2.37–9.29) 3.32 (1.60–6.92) 0.001
No 11 153 1.00 1.00
Expected partner’s reaction to positive HIV test result
Positive 58 190 4.38 (2.09–9.14) 3.56 (1.58–8.01) 0.002

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Dovepres Knowledge of mother-to-child HIV transmission and its
s Negative 9 129 1.00 prevention 1.00
Notes: The assumptions for the application of multivariate logistic regression analysis were fulfilled by using Hosmer and Lemeshow test, and the model was
adequately fitted (P0.715). For explanatory variables having more than two categories, the overall significance of P-value was used. Significant values
are in bold.
Abbreviations: PMTCT, prevention of mother-to-child transmission; COR, crude odds ratio; CI, confidence interval; AOR, adjusted odds ratio; MTCT,
mother-to-child
transmission.

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Abtew et Dovepres
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Ababa and Gondar where 76.8% and 83.5% knew that Ethiopia, also supports these possible explanations. Mothers
MTCT of HIV is preventable.20,23 In this study, 36.9% of who received information on HIV from health care
pregnant women knew that ARV drugs have a preventive provider and who had discussion with partner about
effect on MTCT of HIV, which is much lower than from MTCT were positively associated with increased maternal
Gondar study where 58.4% knew that MTCT of HIV could knowledge of MTCT of HIV.25
be prevented by ARV drugs.20 The poor result in this study
could be due to the fact that pregnant women generally Conclusion
knew that MTCT of HIV is preventable, but they did not Knowledge of ANC attendants about MTCT and PMTCT
know the specific methods of prevention. This may result in the study area was low. This may contribute to
from the ineffectiveness of counseling, health education, increased transmission of MTCT of HIV and lead to
and promotion services given by health facilities. This unsuccessful PMTCT intervention and hinder the
poor result may affect the goal of elimination of MTCT of achievement of the goal of eliminating new HIV infection in
HIV because the strategy is not only overplayed on the children by 2015 laid out in the United Nations Programme
government and the health facilities but every pregnant on HIV/AIDS global plan. Hence, key actors and
woman should also know the critical method of prevention implementors of PMTCT program should address or
of MTCT to take appropriate interventions given by health provide women with accurate and up-to- date knowledge
facilities. of HIV transmission, risk of transmission to babies, and
Among the sociodemographic factors, higher monthly interventions available to reduce and possibly eliminate
expenditure had a positive association with full knowledge the transmission of the virus to children.
on PMTCT of HIV among pregnant women. The positive
effect in this study could be due to the fact that those who Acknowledgments
had higher monthly expenditure might get information The authors would like to thank Bahir Dar University, College
about PMTCT of HIV from different sources of of Medicine and Health Sciences, School of Public Health,
information (newspapers and mass media). Due to this, and Assosa town public facilities. They are also grateful to
they may develop confidence, and this confidence might the data collectors and study participants for their
lead them to independently get access to ANC, PMTCT, cooperation.
and PITC services. Also, they might get the chance to learn
from health professionals. This information may enhance Authors’ contributions
women’s knowledge about PMTCT of HIV. SA contributed to proposal development, data cleaning,
A positive association was reported between data analysis, and manuscript preparation. WA and AA
knowledge on MTCT and PMTCT of HIV and overall contributed to approval of the proposal development, data
knowledge on HIV/AIDS among ANC followers in the analysis, and manuscript preparation. All authors
study area. This finding was consistent with a study contributed toward data analysis, drafting and critically
conducted in Northwest Ethiopia.20 The knowledge on revising the paper and agree to be accountable for all
MTCT and PMTCT of HIV also had a positive association aspects of the work.
with attitude of pregnant women to PITC and expected
partner’s reaction to positive HIV test result during their Disclosure
ANC follow-up. This could be due to the reason that those The authors declare that they have no conflicts of interest
pregnant women who had sufficient in this work.
knowledge about HIV/AIDS had a positive attitude to PITC
during their ANC visit, and women who had smooth com- have more access to information about HIV from different
munication with their partner or expected positive reaction sources.24 A study conducted in Meket District, Northeast
from their partner about HIV positive test result may have
access to get knowledge on MTCT and PMTCT of HIV
from health facilities during HIV testing and counseling,
PMTCT services, communication with partner, and from
other sources like mass media and newspaper. These pos-
sible explanations were consistent with a study conducted
in Uganda, where women who had positive attitude may

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 Dovepres Knowledge of mother-to-child HIV transmission and its
s prevention
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